Cs
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Cs as PDF for free.
More details
- Words: 2,240
- Pages: 10
SAINT MICHAEL’S COLLEGE OF LAGUNA Old National Highway, Platero, Biñan Laguna.
School of Nursing and Midwifery A Partial Fulfillment in Related Learning Experience III
A CASE STUDY of Chronic Gastritis
Submitted by: Angelique A. Malabo BSN 3B Group 8
Submitted to: Ma’am Aimee Agorilla 16January2009
INTRODUCTION
Gastritis is a term used to describe a group of conditions characterized by inflammation of the lining of your stomach. Commonly, the inflammation of gastritis results from infection with the same bacterium that causes most stomach ulcers. Yet other factors — including traumatic injury and regular use of certain pain relievers — also can contribute to gastritis. Gastritis may occur suddenly (acute gastritis), or it can occur slowly over time (chronic gastritis). In spite of the many conditions associated with gastritis, the signs and symptoms of the disease are very similar: a burning pain in your upper abdomen and, occasionally, bloating, belching, nausea or vomiting. In some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For most people, however, gastritis isn't serious and improves quickly with treatment. Chronic gastritis is a chronic gastric lesion, pathologically characterized by nonspecific chronic inflammation of the gastric mucosa. Chronic gastritis can be divided into two categories, primary and secondary. The former is further categorized into superficial, atrophic and hypertrophic types; the latter often complicates gastroduodenal ulcer and gastric cancer. It develops gradually and is more likely to cause a dull pain and a feeling of fullness or loss of appetite after a few bites of food. For many people, though, chronic gastritis causes no signs or symptoms at all. Chronic gastritis may be caused by prolonged irritation from the use of nonsteroidal anti-inflammatory drugs (NSAIDs), infection with the bacteria Helicobacter pylori, pernicious anemia (an autoimmune disorder), degeneration of the lining of the stomach from age, or chronic bile reflux.Many people with chronic gastritis have no symptoms of the condition. An estimated 50% of the world population is infected with H pylori; therefore, chronic gastritis is extremely frequent. H pylori infection is highly prevalent in Asia and in developing countries, and multifocal atrophic gastritis and gastric adenocarcinomas are more prevalent in these areas. The treatment depends on the cause of the gastritis. Antibiotic therapy will treat chronic gastritis caused by infection with Helicobacter pylori. Antacids or other medications, such as cimetidine (to decrease or neutralize gastric acid in the stomach) or proton pump inhibitors such as Prilosec, will usually eliminate the symptoms and promote healing. Medications known to cause gastritis should be discontinued. Gastritis caused by pernicious anemia is treated with vitamin B12. Doctors use several regimens to treat H. Pylori infection. Most use a combination of two antibiotics and a proton pump inhibitor. Sometimes bismuth (Pepto-Bismol) is added to the mix. The antibiotics help destroy the bacteria, and the proton pump inhibitor relieves pain and nausea, heals inflammation and may increase the antibiotics' effectiveness.
To ensure that H. pylori has been eliminated, your doctor may test you again after treatment.
PATIENT’S PROFILE
Name: Jaime M. Gonzales Address: 3rd St. Hi-way Homes Platero Biñan, Laguna Age: 64 Gender: Male Nationality: Filipino Religion: Roman Catholic Birth Date: May 03, 1944 Birth Place: Manila Spouse: Alice Gonzales Attending Physician: Dr. Marquez Admitting Physician: Dr. Pagdanganan Date of Admission: January 05, 2009 Time of Admission: 08:40 pm Chief Complain: epigastric pain Admission Diagnosis: Chronic Gastritis
History of Past Illness: Two days prior to admission, the patient started to experience epigastric pain not associated with fever or nausea. Then after a day, the patient still complained with episodes of epigastric pain. And few hours prior to admission, epigastric pain was accompanied by vomiting. This prompted consult in Biñan Hospital where he was advised to be confined after undergoing a series of examinations. Results of the examinations showed that he has chronic gastritis.
ANATOMY and PHYSIOLOGY
The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste.
Most of the digestive organs (like the stomach and intestines) are tubelike and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The digestive system is made up of the alimentary canal (also called the digestive tract) and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal is the long tube of organs — including the esophagus, stomach, and
intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet (about 9 meters) long. Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty meal, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal. As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth. Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx, a passageway for food and air, is about 5 inches (12.7 centimeters) long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking. From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract. At the end of the esophagus, a muscular ring or valve called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts (2.8 liters) of these digestive juices each day. Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an
adult's stomach has a volume of one fifth of a cup (1.6 fluid ounces), but it can expand to hold more than 8 cups (64 fluid ounces) of food after a large meal. By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular valve at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream. The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body. The liver (located under the rib cage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are essential to digestion. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food. The liver also plays a major role in the handling and processing of nutrients, which are carried to the liver in the blood from the small intestine. From the small intestine, undigested food (and some water) travels to the large intestine through a muscular ring or valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine's main function is to remove water from the undigested matter and form solid waste that can be excreted.
Hormone Regulators The major hormones that control the functions of the digestive system are produced and released by cells in the mucosa of the stomach and
small intestine. These hormones are released into the blood of the digestive tract, travel back to the heart and through the arteries, and return to the digestive system where they stimulate digestive juices and cause organ movement. The main hormones that control digestion are gastrin, secretin, and cholecystokinin (CCK): •
Gastrin causes the stomach to produce an acid for dissolving and digesting some foods. Gastrin is also necessary for normal cell growth in the lining of the stomach, small intestine, and colon.
•
Secretin causes the pancreas to send out a digestive juice that is rich in bicarbonate. The bicarbonate helps neutralize the acidic stomach contents as they enter the small intestine. Secretin also stimulates the stomach to produce pepsin, an enzyme that digests protein, and stimulates the liver to produce bile.
•
CCK causes the pancreas to produce the enzymes of pancreatic juice, and causes the gallbladder to empty. It also promotes normal cell growth of the pancreas.
Additional hormones in the digestive system regulate appetite: •
Ghrelin is produced in the stomach and upper intestine in the absence of food in the digestive system and stimulates appetite.
•
Peptide YY is produced in the digestive tract in response to a meal in the system and inhibits appetite.
Both of these hormones work on the brain to help regulate the intake of food for energy.
Nerve Regulators Two types of nerves help control the action of the digestive system. Extrinsic, or outside, nerves come to the digestive organs from the brain or the spinal cord. They release two chemicals, acetylcholine and adrenaline. Acetylcholine causes the muscle layer of the digestive organs to squeeze with more force and increase the “push” of food and juice through the digestive tract. It also causes the stomach and pancreas to produce more digestive juice. Adrenaline has the opposite effect. It relaxes the muscle of the stomach and intestine and
decreases the flow of blood to these organs, slowing or stopping digestion. The intrinsic, or inside, nerves make up a very dense network embedded in the walls of the esophagus, stomach, small intestine, and colon. The intrinsic nerves are triggered to act when the walls of the hollow organs are stretched by food. They release many different substances that speed up or delay the movement of food and the production of juices by the digestive organs.
DIAGNOSTIC EXAMINATION
Name: Jaime Gonzales Address: 3rd St. Hi-way Homes Platero Biñan, Laguna Exam: Whole Abdomen Ultrasound CC: Epigastric Pain Referred by: Dr. Marquez Sonological Report: The liver is not enlarged. The ducts are not dilated. No focal mass lesion is seen. The gallbladder is not enlarged. The wall is thickened. A high level echo with a diameter of 1.13 cm is seen within the gallbladder. The pancreas and the spleen are unremarkable. The kidneys, ureters and the urinary bladder are unremarkable. The prostate gland measures about 5.0 cm in length x 4.56 cm in width x 3.69 cm in thickness. The echo pattern is non-homogeneous. Calcifications are seen. Impression: Cholecystitis, Cholelithiasis Negative liver, pancreas, and spleen Negative KUB Prostatic enlargement, Prostatic Calcifications
BIBLIOGRAPHY •
www.wikipedia.com
•
http://www.medicinenet.com
•
http://doh.gov.ph
•
http://kidshealth.org
•
Anatomy and Physiology by Gerard Tortora
•
Fundamentals of Nursing
•
Medical and Surgical Book
•
PPD Drug Handbook
•
Handbook for Nursing Diagnosis
•
Nursing Care Plan Book
•
Webster’s Medical Dictionary
•
http://digestive.niddk.nih.gov/ddiseases/pubs/yrdd/
•
http://www.umm.edu/ency/article/000232.htm
•
http://www.mayoclinic.com/health/gastritis
•
http://kidshealth.org/parent/general/body_basics/digestive.html
•
http://www1.us.elsevierhealth.com
•
http://www.rncentral.com
PATHOPHYSIOLOGY Risk factors: eating raw / uncooked foods improper food handling alcohol abuse parasitic infection liver failure kidney failure
• • • • • •
• •
Causes: Ingestion of food contaminated by H. pylori Most common type – B (Chronic gastritis)
fxvc
Inflammation of the mucosal lining of the stomach
• • • •
Manifestations of the ff. signs and symptoms: Nausea and vomiting Upper abdominal discomfort Epigastric pain Ulcer-like distress (relieved by ingestion of foods but exacerbated by spicy foods)
● Diet therapy – limit spices ● Drug therapy - Magnesium If treated: hydroxide c aluminum hydroxide (Maalox) - Aluminum hydroxide (Ampojel) - H2 antagonists - Nizatidine - Famotidine ● Stress reduction techniques - relaxation - guided imagery ● Partial gastrectomy ● Pyroplasty Good RECOVERY ● Vagotomy
Complications may develop such as: If untreated: • hemorrhage • formation of ulcer
Improper functioning of the Gastrointestinal system Improper disposal of body wastes Sepsis DEATH
School of Nursing and Midwifery A Partial Fulfillment in Related Learning Experience III
A CASE STUDY of Chronic Gastritis
Submitted by: Angelique A. Malabo BSN 3B Group 8
Submitted to: Ma’am Aimee Agorilla 16January2009
INTRODUCTION
Gastritis is a term used to describe a group of conditions characterized by inflammation of the lining of your stomach. Commonly, the inflammation of gastritis results from infection with the same bacterium that causes most stomach ulcers. Yet other factors — including traumatic injury and regular use of certain pain relievers — also can contribute to gastritis. Gastritis may occur suddenly (acute gastritis), or it can occur slowly over time (chronic gastritis). In spite of the many conditions associated with gastritis, the signs and symptoms of the disease are very similar: a burning pain in your upper abdomen and, occasionally, bloating, belching, nausea or vomiting. In some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For most people, however, gastritis isn't serious and improves quickly with treatment. Chronic gastritis is a chronic gastric lesion, pathologically characterized by nonspecific chronic inflammation of the gastric mucosa. Chronic gastritis can be divided into two categories, primary and secondary. The former is further categorized into superficial, atrophic and hypertrophic types; the latter often complicates gastroduodenal ulcer and gastric cancer. It develops gradually and is more likely to cause a dull pain and a feeling of fullness or loss of appetite after a few bites of food. For many people, though, chronic gastritis causes no signs or symptoms at all. Chronic gastritis may be caused by prolonged irritation from the use of nonsteroidal anti-inflammatory drugs (NSAIDs), infection with the bacteria Helicobacter pylori, pernicious anemia (an autoimmune disorder), degeneration of the lining of the stomach from age, or chronic bile reflux.Many people with chronic gastritis have no symptoms of the condition. An estimated 50% of the world population is infected with H pylori; therefore, chronic gastritis is extremely frequent. H pylori infection is highly prevalent in Asia and in developing countries, and multifocal atrophic gastritis and gastric adenocarcinomas are more prevalent in these areas. The treatment depends on the cause of the gastritis. Antibiotic therapy will treat chronic gastritis caused by infection with Helicobacter pylori. Antacids or other medications, such as cimetidine (to decrease or neutralize gastric acid in the stomach) or proton pump inhibitors such as Prilosec, will usually eliminate the symptoms and promote healing. Medications known to cause gastritis should be discontinued. Gastritis caused by pernicious anemia is treated with vitamin B12. Doctors use several regimens to treat H. Pylori infection. Most use a combination of two antibiotics and a proton pump inhibitor. Sometimes bismuth (Pepto-Bismol) is added to the mix. The antibiotics help destroy the bacteria, and the proton pump inhibitor relieves pain and nausea, heals inflammation and may increase the antibiotics' effectiveness.
To ensure that H. pylori has been eliminated, your doctor may test you again after treatment.
PATIENT’S PROFILE
Name: Jaime M. Gonzales Address: 3rd St. Hi-way Homes Platero Biñan, Laguna Age: 64 Gender: Male Nationality: Filipino Religion: Roman Catholic Birth Date: May 03, 1944 Birth Place: Manila Spouse: Alice Gonzales Attending Physician: Dr. Marquez Admitting Physician: Dr. Pagdanganan Date of Admission: January 05, 2009 Time of Admission: 08:40 pm Chief Complain: epigastric pain Admission Diagnosis: Chronic Gastritis
History of Past Illness: Two days prior to admission, the patient started to experience epigastric pain not associated with fever or nausea. Then after a day, the patient still complained with episodes of epigastric pain. And few hours prior to admission, epigastric pain was accompanied by vomiting. This prompted consult in Biñan Hospital where he was advised to be confined after undergoing a series of examinations. Results of the examinations showed that he has chronic gastritis.
ANATOMY and PHYSIOLOGY
The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste.
Most of the digestive organs (like the stomach and intestines) are tubelike and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The digestive system is made up of the alimentary canal (also called the digestive tract) and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal is the long tube of organs — including the esophagus, stomach, and
intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet (about 9 meters) long. Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty meal, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal. As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth. Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx, a passageway for food and air, is about 5 inches (12.7 centimeters) long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking. From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract. At the end of the esophagus, a muscular ring or valve called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts (2.8 liters) of these digestive juices each day. Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an
adult's stomach has a volume of one fifth of a cup (1.6 fluid ounces), but it can expand to hold more than 8 cups (64 fluid ounces) of food after a large meal. By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular valve at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream. The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body. The liver (located under the rib cage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are essential to digestion. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food. The liver also plays a major role in the handling and processing of nutrients, which are carried to the liver in the blood from the small intestine. From the small intestine, undigested food (and some water) travels to the large intestine through a muscular ring or valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine's main function is to remove water from the undigested matter and form solid waste that can be excreted.
Hormone Regulators The major hormones that control the functions of the digestive system are produced and released by cells in the mucosa of the stomach and
small intestine. These hormones are released into the blood of the digestive tract, travel back to the heart and through the arteries, and return to the digestive system where they stimulate digestive juices and cause organ movement. The main hormones that control digestion are gastrin, secretin, and cholecystokinin (CCK): •
Gastrin causes the stomach to produce an acid for dissolving and digesting some foods. Gastrin is also necessary for normal cell growth in the lining of the stomach, small intestine, and colon.
•
Secretin causes the pancreas to send out a digestive juice that is rich in bicarbonate. The bicarbonate helps neutralize the acidic stomach contents as they enter the small intestine. Secretin also stimulates the stomach to produce pepsin, an enzyme that digests protein, and stimulates the liver to produce bile.
•
CCK causes the pancreas to produce the enzymes of pancreatic juice, and causes the gallbladder to empty. It also promotes normal cell growth of the pancreas.
Additional hormones in the digestive system regulate appetite: •
Ghrelin is produced in the stomach and upper intestine in the absence of food in the digestive system and stimulates appetite.
•
Peptide YY is produced in the digestive tract in response to a meal in the system and inhibits appetite.
Both of these hormones work on the brain to help regulate the intake of food for energy.
Nerve Regulators Two types of nerves help control the action of the digestive system. Extrinsic, or outside, nerves come to the digestive organs from the brain or the spinal cord. They release two chemicals, acetylcholine and adrenaline. Acetylcholine causes the muscle layer of the digestive organs to squeeze with more force and increase the “push” of food and juice through the digestive tract. It also causes the stomach and pancreas to produce more digestive juice. Adrenaline has the opposite effect. It relaxes the muscle of the stomach and intestine and
decreases the flow of blood to these organs, slowing or stopping digestion. The intrinsic, or inside, nerves make up a very dense network embedded in the walls of the esophagus, stomach, small intestine, and colon. The intrinsic nerves are triggered to act when the walls of the hollow organs are stretched by food. They release many different substances that speed up or delay the movement of food and the production of juices by the digestive organs.
DIAGNOSTIC EXAMINATION
Name: Jaime Gonzales Address: 3rd St. Hi-way Homes Platero Biñan, Laguna Exam: Whole Abdomen Ultrasound CC: Epigastric Pain Referred by: Dr. Marquez Sonological Report: The liver is not enlarged. The ducts are not dilated. No focal mass lesion is seen. The gallbladder is not enlarged. The wall is thickened. A high level echo with a diameter of 1.13 cm is seen within the gallbladder. The pancreas and the spleen are unremarkable. The kidneys, ureters and the urinary bladder are unremarkable. The prostate gland measures about 5.0 cm in length x 4.56 cm in width x 3.69 cm in thickness. The echo pattern is non-homogeneous. Calcifications are seen. Impression: Cholecystitis, Cholelithiasis Negative liver, pancreas, and spleen Negative KUB Prostatic enlargement, Prostatic Calcifications
BIBLIOGRAPHY •
www.wikipedia.com
•
http://www.medicinenet.com
•
http://doh.gov.ph
•
http://kidshealth.org
•
Anatomy and Physiology by Gerard Tortora
•
Fundamentals of Nursing
•
Medical and Surgical Book
•
PPD Drug Handbook
•
Handbook for Nursing Diagnosis
•
Nursing Care Plan Book
•
Webster’s Medical Dictionary
•
http://digestive.niddk.nih.gov/ddiseases/pubs/yrdd/
•
http://www.umm.edu/ency/article/000232.htm
•
http://www.mayoclinic.com/health/gastritis
•
http://kidshealth.org/parent/general/body_basics/digestive.html
•
http://www1.us.elsevierhealth.com
•
http://www.rncentral.com
PATHOPHYSIOLOGY Risk factors: eating raw / uncooked foods improper food handling alcohol abuse parasitic infection liver failure kidney failure
• • • • • •
• •
Causes: Ingestion of food contaminated by H. pylori Most common type – B (Chronic gastritis)
fxvc
Inflammation of the mucosal lining of the stomach
• • • •
Manifestations of the ff. signs and symptoms: Nausea and vomiting Upper abdominal discomfort Epigastric pain Ulcer-like distress (relieved by ingestion of foods but exacerbated by spicy foods)
● Diet therapy – limit spices ● Drug therapy - Magnesium If treated: hydroxide c aluminum hydroxide (Maalox) - Aluminum hydroxide (Ampojel) - H2 antagonists - Nizatidine - Famotidine ● Stress reduction techniques - relaxation - guided imagery ● Partial gastrectomy ● Pyroplasty Good RECOVERY ● Vagotomy
Complications may develop such as: If untreated: • hemorrhage • formation of ulcer
Improper functioning of the Gastrointestinal system Improper disposal of body wastes Sepsis DEATH
